Mediation Application Form

Do both parties agree to ECYS mediating?

Applicant’s First Name

Applicant Second Name

Applicant’s Surname

Date of Birth

Full Address

Home No

Mobile No

Name of Conflicting Party

Age of Conflicting Party

Your relation to the conflicting party

Date the conflict started

Have you tried mediation before, and if so, what was the outcome?

Please describe the conflict:

What you have tried to do to resolve the conflict, and what was the outcome?

Have there been any legal proceedings, and if so, provide full details and outcomes?

What outcome do you hope from the mediation?

Print Your Name:

Date